When it comes to respecting home sleep testing, the CEO of Itamar Medical believes the American Academy of Sleep Medicine (AASM) has finally come around. Evidence for the belief can be found in the AASM’s Accreditation of Out of Center Sleep Testing for Adult Patients, a program announced in February 2011.

With the stated purpose “to meet the changing needs of our members, sleep disorders centers, and the sleep medicine field,” the new program signals what Dov Rubin, PhD, believes is a growing acceptance of home sleep testing on the part of AASM.

“The potential patient benefits are enormous,” says Rubin. “The AASM is now actively preparing their members to capitalize on home testing and use it to their advantage. This occurred at the recent winter meeting in La Jolla [Calif] where they told membership that it is not a question of ‘if’ home sleep testing will come around, but ‘when’ and, more importantly, how the membership should capitalize on these developments.”

The newfound clinical respect coincides with a growing realization that home sleep testing can peacefully coexist with the business interests of in-lab testing. Working together to see and ultimately help more people is the idea, and the AASM’s new stance could go a long way toward this goal.

The 50% Rule

Rubin suspects that the AASM’s friendlier approach is likely driven by a realization that sleep laboratories have inherent limitations. “I like to say that 50% of the population would not walk into a sleep lab if their life depended on it,” says Rubin, who holds a doctorate in biomedical engineering from the University of Southern California. “The AASM realizes that they can now provide vital medical help for a larger percentage of the population just as we also know that home sleep testing is not for everyone. For more difficult cases, it is obvious that an in-lab sleep center will be more appropriate. This will convert the sleep lab into a true sleep health center. It took the leadership of the AASM to give the blessing, and they have really turned the corner.”

A shift in AASM philosophy is no small matter, and the change of heart could presage a day when many more CPAP prescriptions are given out based on home results alone. “That is always a question that concerns the insurance companies, because they are afraid of an explosion in the use of CPAP,” says Rubin. “I don’t know whether more home sleep testing acceptance will bring an increase in cost. Quite the opposite. Statistics show that for every dollar spent on preventive medicine, $12.50 is saved 10 years down the road. If insurance companies are looking at this as a long-term cost savings, it is well worth it.”

Devoted Following

DME providers with long-standing sleep lab partnerships have relied on the PAT® (peripheral arterial tone) signal technology found in Itamar’s WatchPAT device for a long time. Rubin attributes the loyalty to ease of use. “You get logical and simple usage with the WatchPAT,” says Rubin. “It makes good intuitive sense. It is not some sort of a tethered medical device, and it is not intimidating.”

Right now, WatchPAT is FDA-cleared only for people age 17 and above. Company officials have fielded a lot of requests from lab directors and sleep physicians, and they are providing data to regulators in an effort to expand the age range to include younger patients. Rubin estimates approval could materialize in the next 6 months, but it depends on the FDA.

Home Sleep Harmony

These days, there is a realization that sleep labs and home testing can work together harmoniously. For example, savvy DME providers can bring in those undiagnosed sleep apnea sufferers, and send the more complex cases to sleep labs. “My estimate is that home sleep testing will increase sleep lab business by at least 30% because there will be referrals,” explains Rubin. “To this, add Board-certified interpretation of results, patient treatment, and testing which will ultimately add up to more business for sleep labs.”

Reimbursement for home sleep testing has gone down, as has reimbursement for in-lab sleep tests. PAT technology received its own code (95800) this year, and with it what Rubin deems a “fairly good price” of about $205 per test. Since it is a new code, providers can count on this Medicare dollar amount remaining fixed for the next 2 years. Private payers, on the other hand, may be lower or higher depending on the company.

Future is Bright

The massive potential of the sleep market is now considered all but a sure thing among sleep labs and sleep industry manufacturers. And, as patient awareness grows, clinical knowledge and infrastructure inevitably rises to meet the challenge. Rubin believes the modern age of sleep medicine is quickly developing into an era where turf battles are tossed aside and patients take center stage. Telemedicine and physician- friendly, web-based access to sleep studies, as offered by WatchPAT, becomes yet another modality for patient ease of use and treatment.

Reimbursement wars have largely focused on the diagnostic utility of ambulatory sleep studies, but innovations such as the PAT signal technology have a distinct place among a variety of options. With hypertension affecting roughly 50 million Americans, and sleep apnea pegged as one of the causes, the stakes are high and cooperation is essential. “We want to start with the common understanding among sleep physicians that ambulatory sleep monitoring is their friend, not their enemy,” says Rubin. “We are trying to show sleep physicians that there is nothing to be afraid of here, and these ambulatory sleep studies are an adjunct to what they do — not much different from what they do today. Sleep physicians still have the 6 to 8 channels of polysomnographic data, and they analyze it just as they would any other polysomnogram.”

In a recent issue of Sleep Diagnosis and Therapy, Koby Sheffy, PhD, essentially agreed with Rubin, writing that the role of unattended sleep studies in the management of sleep apnea patients has substantially evolved in recent years. While PSG will continue to be recognized as the most comprehensive sleep study paradigm, Sheffy believes it will probably not remain as the only testing modality. “Increased clinical demands, shifts in health care environment, and technological developments will contribute to a growing acceptance of simpler diagnostic options,” writes Sheffy in a 2009 article entitled Shattering the Black Box Myth: PAT Technology in Action. “Thus, over the next few years, sleep labs will be required to assess their services and determine how to adapt to and benefit from the shifting landscape.”

Part of this landscape will undoubtedly include the physiological signals generated by PAT. “At first glance, systems incorporating PAT signals might be perceived as yet another black box,” adds Sheffy. “Understanding the simple physiological rationale upon which it is based shows that it is far from being a mystery.”

AASM officials say that sleep service entities interested in obtaining accreditation as a provider of out of center sleep testing can go to http://www.aasmnet.org and download an application. Accompanying Standards for Accreditation of Out of Center Sleep Testing are also available for download at the Web site. The AASM’s accreditation department can be reached via e-mail: ocstaccreditation@aasmnet.org

Sleep, both adult and pediatric, is the third pillar of the American Thoracic Society. At the International Conference, clinical and research experts provide insights into all areas of sleep medicine, though a particular focus at the conference is obstructive sleep apnea and the affect of sleep problems on people with lung disease. Below is a select list of topics that will be presented during ATS 2011 (return mid-January to review individual session details, including session topics and speakers):

Sleep

Clinical Year in Review: Sleep Apnea

Clinical Impact of Pathophysiology on Treatment of OSA/Hypopnea Syndrome

The clash between the American Academy of Sleep Medicine (AASM) and the Board of Registered Polysomnographic Technologists (BRPT) may be 4 months old, but it shows no sign of cooling down.

It’s no secret that tension has been growing between the Board of Registered Polysomnographic Technologists (BRPT) and the American Academy of Sleep Medicine (AASM). Testy written exchanges are posted at www.brpt.org for all to see, starting with the December 17, 2010, letter to Janice East, RPSGT, R. EEG T., president of BRPT.

That letter, which “stunned” East and her colleagues, told of the AASM’s decision to develop a certification exam for sleep technologists, to be administered through the American Board of Sleep Medicine (ABSM). In the letter, the AASM cited concerns with the pass rate for the BRPT’s Registered Polysomnographic Technologist (RPSGT) examination, saying that “a majority of otherwise qualified sleep technologists currently employed at sleep centers are unable to obtain the necessary credentials required to stay in the profession.”

East responded in a strongly worded letter to ABSM President Nathaniel F. Watson, MD, on January 10, 2011. According to East, the BRPT had collaborated with the AASM 10 months earlier to launch the Certified Polysomnographic Technician (CPSGT) examination, which was developed to put a large number of “certified” sleep personnel into the field, and to assist with legislative requirements in states where there was insufficient time for technicians to become RPSGTs. “The CPSGT exam came about in direct response to a request from the AASM,” wrote East. “We invested in excess of $100,000 in the development of a strong certificate-level exam, treating the process with such a sense of urgency that we developed and launched the CPSGT exam within nine months. The CPSGT exam development process included both AASM and AAST input, item review, and exam approval.”

In response to the AASM concern that too few technologists were passing the RPSGT exam, East wrote that the CPSGT exam had yielded a consistent 83% passing rate for 2010. Technicians with limited experience, she wrote, would be put on a tiered progression toward earning the RPSGT credential. The RPSGT pass rate for 2010 was 62%, an improvement over previous years.

At press time, little had changed between the BRPT and the AASM. However, East indicated that the BRPT is now more likely to expand its mission to include education. In the past, the BRPT had administered the exams, with AASM supplying many of the courses to prepare. With those traditional roles no longer in place, that could change.

Below is an recent interview with East to get her opinions on the controversy. As a 2nd-year president of the 32-year-old organization, East spoke candidly about future plans, frustration with the AASM, and the pride of achievement that many technologists feel when passing the RPSGT exam.

Is there room for two sheriffs, so to speak, in the sleep certification/credentialing world?
Janice East, president of the Board of Registered Polysomnographic Technologists (BRPT): Probably not. We thought we were working toward building on our exam and working with the AASM collaboratively to provide the best possible exam and the best preparation.

We would give feedback to the AASM and the American Association of Sleep Technologists (AAST) so they could provide the proper education to prepare for the exams. Then the AAST makes the statement that they are supporting all exams that lead to some type of credentialing for technologists, which is amazing because they are a membership organization, and they are supporting an exam without even knowing what it is.

Why did you write earlier this year that you were “stunned” by the AASM’s certification exam announcement?When this came up, it was a surprise to us. We had met in September 2010 with the technologists on our board, the entire AAST board, and Jerry Barrett [executive director of the AASM]. We had a long discussion and reviewed our exam processes.

We had what we thought was a good meeting discussing RPSGT recertification, and we shared all of our statistics, which we always do with AASM and AAST. We left that meeting feeling good. About 60 days later, we received a letter from the ABSM president saying that they were going to start their own technologist exam.

Is there any way that this difficult matter can be mended? Have you spoken with the AASMNate Watson (Nathaniel Watson, MD, president of the ABSM) gave me his cell phone number, and I did speak with him. I asked specifically if there was any way for us to sit down with the AASM and talk about this. He said no.

We know that pass rates were a matter of contention. What can you tell us about those discussions?We’ve been in some uncomfortable meetings, and we have been pushed very hard to lower the score required to pass the exam. AASM basically told us to just arbitrarily lower the passing score from whatever it’s set at. We follow best practices in credentialing to develop the exams and they wanted us to randomly change it so more people pass.

What is the ABSM’s main complaint about the RPSGT exam?Their complaint about our exam is that it’s not really testing what people are doing on the job. However, we performed a job task analysis, and that is the core of creating an exam. We did that analysis in 2009, surveying RPSGTs about their everyday job tasks, rating how important and how frequent these are done.

The job task analysis is standard for any kind of certification exam and it’s used to develop the exam content outline or blueprint. Subject matter experts (SMEs) are used to finalize the exam blueprint, working in conjunction with a psychometrician.

Do you plan on addressing this topic during public speaking engagements?
We always get out to the state societies and anywhere we are invited to speak—including regional and national meetings. Going forward, it is going to be key for us to make sure people understand the role of our credential, how it came about, the value of it, and how it is being used. Awareness of our strengths, and the fact that BRPT has been delivering the RPSGT exam for 32 yrs and is not going anywhere, are important messages.

What concerns you most about the AASM certification exam?
It’s not so much that there is a competing credential. My concern has to do more with the reason that AASM said that they put it together. In the letter we received from Nate Watson, he stated that “…for a number of years, sleep physicians who are medical directors of sleep centers have expressed concern that certification by the BRPT does not ensure professional readiness.” In all of the meetings we’ve had with the AASM leadership, this concern was never expressed to us. I asked for data supporting this statement in a phone call with Dr. Watson. He did not respond to this inquiry. We don’t have any information about the exam, so it’s hard to comment on the exam itself. Based on the information they shared with us about why they created the exam, it’s a little frustrating.

What kind of information had you been sharing with the AASM and AAST?
We’ve been working with the AASM and AAST for a long time sharing specific information about our exams that showed where people were having problems with the questions, and what education AAST should be able to provide to help people with the exam. One thing you have to remember is that 70% of the people taking the RPSGT exam are coming through pathway #1, which means they are trained on the job.

They have 18 months experience that varies from somebody coming off the street and being shown how to operate the machine, to somebody who’s getting extensive education in a medical center that allows on-the-job training. Our lowest pass rate comes from pathway #1.

Prior to this controversy, how did you view the BRPT’s role?
I always viewed AAST as the education provider, and we were the independent credentialing organization. AASM has stepped into the arena for technical education as well. AASM is a physician membership organization and AAST is a technologist membership association. Both represent the members of their organizations. BRPT is independent of oversight from these groups, but was working collaboratively in areas of mutual interest, such as state licensure issues, improving educational offerings for recertification, and other related activities.

Will you now pursue the educational arena?Traditionally we stayed out of education, and there are some limitations put on us by our National Commission for Certifying Agencies (NCCA) accreditation. We can’t say ‘You have to take our education modules. You have to complete only our education packets in order to sit for our exam.’ We can, however, provide education. We have not really done that because we viewed that as the role of AAST and AASM.

Moving forward, however, we are investigating avenues for providing more education. We can offer educational opportunities, both for people taking our exam, and for recertification.

Do you believe there will be adequate demand for more educational opportunities?
Yes, but it’s hard for some technologists, especially in rural areas and some countries outside the U.S., to get continuing education. People still tend to think they have to go to conferences, which is not the case. We will offer some webinars for a fee, and some other online pieces at no charge, for recertification.

What do you say to critics who say the RPSGT exam is too difficult?
We have a very strong credential, and it has been around for 32 years. Our message board and a new Facebook page have sparked a vigorous response over concern about the exam—and concern that a new exam is being created. Some people ask:
Why is AASM involved? Is it all about money?

What other types of concerns are you seeing on message boards?People are concerned about the implications for patient care. You’ve got a physician-driven organization talking about lowering the passing score, and now they are creating another exam. The concern is: What kind of exam is it going to be? Is it going be easy? Sure, there are some people out there who are just happy because it will probably be easier.

If you study, you’ll be able to pass our exam. People just aren’t prepared. We have a 67% pass rate right now for the RPSGT. I asked Nate Watson what pass rate AASM would find acceptable. He did not have an answer, and there is no published literature that addresses that question.

There is a rumor that some RPSGTs are looking to start another sleep technologist membership organization. You see that on some of the blogs and message boards, but I don’t know. I’ve talked to some physicians and technologists as well who have not renewed their membership in AAST or AASM—especially the techs. And some physicians are not renewing for AASM.

Do you believe all of this will lead to a loss of candidates for BRPT?
Our goal is to get information out there. If candidates are going to make a choice about exams, we want them to be educated. We are certainly going to focus on the value of our credential. Unfortunately, we don’t have the financial support that the AASM has. However, we enjoy a wonderful professional standing.

Our NCCA accreditation is key. In the professional credentialing industry, NCCA accreditation represents compliance with best industry standards. It provides strong, independent, third party validation of the RPSGT exam process, which has been instrumental in winning recognition of the RPSGT credential as proof of professional competency in state legislatures, before state medical and licensing boards, and in CMS reimbursement guidelines.

Even though some may complain about it being a difficult exam, they are so proud to have it. You’ll see on the message boards that people don’t want a lower passing score or an easier exam. They’ve worked hard to get where they are, and they are proud of what they have achieved. It’s a fair exam. It is the gold standard in the field of sleep.

INFO BOX
In 1979 the Board of Registered Polysomnographic Technologists (BRPT), a committee of the Association of Polysomnographic Technologists (which later changed its name to the American Association of Sleep Technologists [AAST]), administered the first registry examination at the New York State University Sleep Disorders Laboratory in Stony Brook. Since that time, more than 17,000 technologists have obtained an RPSGT credential. The RPSGT exam is accredited by the National Commission for Certifying Agencies (NCCA).

The American Board of Anesthesiology (ABA) announced that the American Board of Medical Specialties (ABMS) has approved the ABA’s application for sponsorship of subspecialty certification in sleep medicine. The 2011 ABMS sleep medicine certification exam will be the final opportunity for physicians to apply under the Practice Pathway; after this exam, all first-time applicants must have completed a formal sleep medicine fellowship program. The exam will be offered Nov. 10, 2011, by these six member boards of the ABMS:

American Board of Anesthesiology (ABA)
American Board of Family Medicine (ABFM)
American Board of Internal Medicine (ABIM)
American Board of Otolaryngology (ABOto)
American Board of Pediatrics (ABP)
American Board of Psychiatry and Neurology (ABPN)

The following shows the registration dates that are currently available from each board:

All dates and deadlines are subject to change. Physicians must submit an application through the board in which they hold their primary certification. Please consult the website of the appropriate board for more details.

The clash between the American Academy of Sleep Medicine (AASM) and the Board of Registered Polysomnographic Technologists (BRPT) may be 4 months old, but it shows no sign of cooling down.

It’s no secret that tension has been growing between the Board of Registered Polysomnographic Technologists (BRPT) and the American Academy of Sleep Medicine (AASM). Testy written exchanges are posted at www.brpt.org for all to see, starting with the December 17, 2010, letter to Janice East, RPSGT, R. EEG T., president of BRPT.

That letter, which “stunned” East and her colleagues, told of the AASM’s decision to develop a certification exam for sleep technologists, to be administered through the American Board of Sleep Medicine (ABSM). In the letter, the AASM cited concerns with the pass rate for the BRPT’s Registered Polysomnographic Technologist (RPSGT) examination, saying that “a majority of otherwise qualified sleep technologists currently employed at sleep centers are unable to obtain the necessary credentials required to stay in the profession.”

East responded in a strongly worded letter to ABSM President Nathaniel F. Watson, MD, on January 10, 2011. According to East, the BRPT had collaborated with the AASM 10 months earlier to launch the Certified Polysomnographic Technician (CPSGT) examination, which was developed to put a large number of “certified” sleep personnel into the field, and to assist with legislative requirements in states where there was insufficient time for technicians to become RPSGTs. “The CPSGT exam came about in direct response to a request from the AASM,” wrote East. “We invested in excess of $100,000 in the development of a strong certificate-level exam, treating the process with such a sense of urgency that we developed and launched the CPSGT exam within nine months. The CPSGT exam development process included both AASM and AAST input, item review, and exam approval.”

In response to the AASM concern that too few technologists were passing the RPSGT exam, East wrote that the CPSGT exam had yielded a consistent 83% passing rate for 2010. Technicians with limited experience, she wrote, would be put on a tiered progression toward earning the RPSGT credential. The RPSGT pass rate for 2010 was 62%, an improvement over previous years.

At press time, little had changed between the BRPT and the AASM. However, East indicated that the BRPT is now more likely to expand its mission to include education. In the past, the BRPT had administered the exams, with AASM supplying many of the courses to prepare. With those traditional roles no longer in place, that could change.

In the full in-depth interview, which will be available next week, East will give her candid opinions on the controversy, about future plans, frustration with the AASM, and the pride of achievement that many technologists feel when passing the RPSGT exam.

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